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Ina May Gaskin, Marsden Wagner Speak Out on Cytotec Induction of Birth

October 9, 2007

Nashville, TN NBC affiliate WSMV ran a piece in April on the use of the anti-ulcer drug Cytotec in the induction of labor, which was just brought to my attention via Well Preserved. From the piece:

The manufacturer of the drug warns against it for speeding up childbirth, and the Food and Drug Administration has never approved it for that purpose and has issued an alert against using it in childbirth.

Despite these warnings, local ob/gyn Jeffrey Lodge was quoted for the story as saying,

“I don’t know anyone in the middle Tennessee area who doesn’t use Cytotec in one way or another. We use so many medicines off label, but Cytotec today is within the standard of care for obstetrics.”

That’s great – the manufacturer *and* the FDA warn against using it for this purpose, but what’s a little off-label drug use in birth? The reporter notes one problem – women aren’t aware that this isn’t a standard, approved drug for the purpose – “Patients have said that at many Nashville hospitals, doctors gave them no indication that there’s a controversy about using Cytotec to induce birth.”

Renowned Farm midwife Ina May Gaskin weighed in, commenting:

“With any kind of induction where you’re really revving up the uterus and making it work harder than it would on its own, you run some risk…I’m not saying every woman is in danger. I don’t think that. It’s just the Russian Roulette aspect of it because we’re not able to tell which women are gonna have this long latent reaction or ultra sensitivity some people seem to have.”

The WSMV piece also profiles families who have filed suit due to complications following Cytotec inductions.

Dr. Marsden Wagner authored a commentary on Cytotec inductions for Midwifery Today which is well worth a read for background on the issue.

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36 Comments leave one →
  1. October 9, 2007 7:23 pm

    So stupid.

    For years I worked with many different hospitals and doctors, many of who used Cytotec for induction purposes. They would tell the moms that it was to rippen the cervix. They didn’t happen to mention the constant cramping and that babies don’t like it.

    About 5 years ago I decided that I would only work with a CNM at a small local hospital on Laguna Beach. In the event that an induction was needed she would use the Foley Bulb method.

    Foley bulb: A Foley catheter, typically used to drain the bladder, has an inflatable bulb at the tip to hold it in place. For labor induction, a 30cc bulb is placed in the cervix and inflated. Mechanical stretch can cause reflex uterine contractions and force dilation to about 3 centimeters. In some situations, saline is infused through the catheter, which can help separate the membranes from the uterine wall, releasing hormones and phospholipases.

    It was gentle, did not require a hospital stay and worked beautifully with no side effects.

    Once Cytotec or Prostaglandin gel are inserted…you can’t take it out. So,if mom or baby doesn’t like it or respond favorably…Oh well…”Section her”

    Rachel, you pick such educational topics. It’s such a great service to women and educators alike.

    Cyndi

    http://www.mybirthteam.com

  2. October 9, 2007 11:49 pm

    I agree with Cyndi, Rachel. Your blog is probably one of the best sources of unique, focused information about reproductive health. It is one of my go-to sites for RH information. Keep up the good work. ❤

  3. October 10, 2007 7:25 am

    As a non-medical person, stories like this scare the crap out of me. I have to believe, in order to work up the courage to go to my doctor, that my doctor has my best interest at heart and is up to date on which medicines are safe to use in which ways and is making the best choices for me that she can.

    I’m putting my life in her hands. I want to know that she’s being cautious with it.

    But I guess this is just a good reminder that a lot of doctors don’t see that relationship the same way.

    Still, it really bothers me that they don’t.

  4. snikta permalink
    October 10, 2007 7:29 am

    Thank you. This is one of those things that I’m filing away for (near) future reference. Though it is beginning to look like we won’t have to worry about the doc wanting to induce.

  5. October 10, 2007 7:33 am

    Cindy and Caitlain, thank you very much. I appreciate you both as commenters, too.

    B, I think that’s exactly the thing – people by and large go to doctors because they expect them to know what the right thing to do is, and to tell us about what they’re doing. You assume when they give you a drug that there are no real worries or they wouldn’t give it to you. I think it’s especially hard in situations like labor or critical illness to really demand answers, especially to questions you don’t know you need to ask (the general you, not the specific you).

    Snikta, how close are we now?

  6. bridgett permalink
    October 10, 2007 8:58 am

    Gah. I remember when Pitocin was the go-to drug for doctors looking to speed up the assembly line of labor and delivery. Anything to preserve health insurers’ profits, right?

  7. October 10, 2007 9:00 am

    As a woman who is having some medical issues that have nothing to do with ulcers or childcare, I have to say that this particular topic grabbed my attention for the same reasons B. so eloquently stated. I heard a midwife say once, babies come on their own time. One question from people smarter than me on this, is this to get women to just hurry up and give birth so another woman can, I don’t know, hurry up and give birth?

    I am seriously about to go Howard Beale about medical care.

  8. October 10, 2007 9:16 am

    Is this drug used on women that are way over their due date? I mean, thats why you induce, right? Aren’t there inherent dangers to the act of inducement itself? And if the catheter thingie is safe, why don’t more doctors use it? Over-reliance on drugs? I feel weird even asking this stuff, but now that I’ve read the article and comments…I’m curious.

  9. October 10, 2007 10:05 am

    Mack:

    First of all, there are legitimate reasons to induce, unfortunately most inductions (at least in my state-California) are elective. The “Your baby is measuring too big” is the #1 manipulation here. Most women don’t even get to their due dates!

    I remember one birth I was at. We were one of 15 women on 15 room L&D floor. Of course the only room that had any sound coming from it… was ours. I asked our OB why it was so busy, he said “because it’s induction day!” I asked him how many of the inductions were medically necessary…”One for a low AFI” (amniotic fluid index) I was shocked! We were the only room not being induced and one of four that did not have a C-section.

    The Foley catheter is a “safer” approach to a medically needed induction, but any form of induction has risks, including herbs and castor oil. If a baby is not ready or the mom is not physically or mentally ready (I believe that birth is 85% psychological)…it will not be easy no matter what method you use.

    Many women sign up for an induction with no questions asked. That says a lot about our lack of education and feelings of inadequacy. We wouldn’t plan a wedding without doing research, why would we plan the birth of our children without that same sense of commitment?

    Cyndi

    http://www.mybirthteam.com

  10. October 10, 2007 10:16 am

    Mack, very few women get “way over their due date” these days, so basically, no. Sometimes a woman will come in for an appointment at, say, exactly 40 weeks (which is an estimate, anyway), and the doc will say, “Well, let’s go ahead and induce you and you can have this baby today.” It’s definitely not always done for a medical reason. Even if women are technically past their “due date,” that’s not always a problem – as ‘coma says, “babies come on their own time,” but the medical environment is not always so flexible, sometimes treating birth as an assembly line process, as Bridgett mentions.

    I would almost change my above “not always” to a “rarely” and “sometimes” to “usually,” but I tend to be conservative with frequency words.

  11. October 10, 2007 11:36 am

    Sometimes a woman will come in for an appointment at, say, exactly 40 weeks (which is an estimate, anyway), and the doc will say, “Well, let’s go ahead and induce you and you can have this baby today.” It’s definitely not always done for a medical reason.

    I’m not a fan of induction, speaking as I do from the cheap seats.

    But I’ve known a LOT of pregnant women. (That happens to us infertile types….sit next to me and get pregnant!) The suggestion to inducement may not seem medically necessary on paper, but I understand why a lot of doctors offer it at a 40week appointment.

    Most of the pregnant women I’ve known are strung out from lack of sleep, severly constipated, in excruciating back pain and psychologically weary by their 40th week. Many of them have cleaved to the idea of inducement like a drowning man to a water fountain.

  12. October 10, 2007 11:58 am

    Kat, I get that, but I have a problem with offering it as “relief” when it’s not only not medically necessary, but the specific it method is contraindicated. One thing can happen with this type of induction is that the uterine muscles contract really hard, wearing the woman (and the uterus) out, sometimes making it harder to actually be able to go through with a vaginal birth, then they have the c-section recovery and whatnot. I’m not sure women are being properly informed of what they’re getting into when they seek that “relief.”

    I watched some show a few weeks back where a woman was attempting a home birth. She was worn out and cranky, and the midwife just flat out told her, “Everything is going to suck until the baby comes out. It just is.” (And I know, it doesn’t totally suck for everybody) I guess I’m not convinced using a contraindicated drug or doing an unnecessary induction is a great idea just for trying to reduce the suck.

  13. October 10, 2007 12:06 pm

    When I volunteered worked in the Birth Center of my hospital, every birth that wasn’t in some way an emergency (that is, the woman showed up at the hospital with or without an ambulance but definitely in labor right that second) was induced. That was just how it went.

    Women made appointments directly with the hospital (it was my job to wheel them in when they came on their own, and to do some of the basic check-in stuff), the nurses provided most of the care, and then whenever it was time (usually about 12 hours after the non-emergency ones showed up), they were induced. After the birth, they had 12-24 hours to recover (depending on what their health insurance – again, barring emergencies) and I wheeled them back out to their cars, installed the car seat,* and off they went.

    Usually, during the time they were there a nurse would conduct a breastfeeding class and offer them a line of formula if they didn’t want that, or wanted to supplement (we carried everything – soy and non-soy, iron supplemented, extra fat, low fat, and so on and so forth) and showed them how to put together bottled and stuff. And even though it was completely and thoroughly against the rules, I usually wound up with 1-3 babies on my hands (in their little criblets, of course) while the mothers slept, because it was a birth center (babies stay with moms) instead of a maternity ward (babies go to nurseries); unless there was something serious going on, even the immediate bathing and stuff was done in-room and the baby was immediately returned for bonding and nipple-finding. We were good like that.

    So.. yeah. My experience is that even at the best hospitals (my hospital was a wealthy one, and our birth center was state of the art, with some of the best OB/GYNs contracted around, including the man who delivered me) operate in a very ‘assembly-line’ fashion. Compared to many of the stories I’ve read online, our little birth center seems like absolute paradise… and that’s pretty scary. (Not least because I was 15 during all these stories about me running the nurse’s center, watching babies, changing diapers, helping get labs done, and all that. And, y’know, the hospital closed that year, so I don’t even have the option of going there if/when I should get pregnant.)

    * California law says that we can’t let them go without a properly installed car seat. If they don’t have one, we have to give it to them. And they’re not allowed to put it in themselves; I had to do it for them, and then check to make sure that all of the connections and things were correct. Then, I had to watch them put the baby in the car seat, because some people want to hold their babies and that’s… somehow bad for us, liability-wise. Then they could drive off.

  14. October 10, 2007 1:08 pm

    Thank you Rachel! I’m a longtime lurker and am glad to see you weigh in on the Cytotec controversy. I’ve done some research on my own and am very uncomfortable with the rates of infant death, maternal death, uterine rupture, etc. with the off-label use of this STOMACH ULCER DRUG!

    At my last prenatal visit I specifically asked my OBGYN not to use Cytotec if I “need” to be induced. Turned out he’d used it on a few patients in the past and had never had a problem but he will respect my wishes – I’ve outlined this in my birth plan just in case. And he had not heard a word about how controversial this drug is, or that the FDA & the manufacturer had both warned against using Cytotec to induce labor. He was very surprised! Sadly it’s up to us to do our own research on these matters. Informed consent can’t happen if our health care providers don’t have the information!

  15. emvest permalink
    October 10, 2007 1:14 pm

    Thanks for the link!
    You pulled great quotes from the story and are reaching many women! Good for you!

  16. October 10, 2007 1:34 pm

    Mag, thank you for sharing that. I think it’s an important point, that even going to Special Mom-Friendly Institution doesn’t always guarantee that the practices are what you would want or expect them to be.

  17. October 10, 2007 1:42 pm

    Chloe, good for you. It’s more than a little disturbing that your doc had been using the drug in some cases but had no idea there was any possible problem.

  18. Malia permalink
    October 10, 2007 2:24 pm

    OMG!!!!! Lodge was my doctor when I had JBelle! I was induced and ended up having to have a C-section! I have no idea if that drug was used or not, though. I assumed I was given Pitocin and really don’t remember if I looked at the bag that was hooked up to me or not.

  19. Malia permalink
    October 10, 2007 2:26 pm

    I should say, in all fairness, I asked to be induced for reasons that are too long and complicated to put here. But still, it would be interesting to know what I was given for my induction.

  20. October 10, 2007 2:35 pm

    Malia,

    Cytotec is a small pill that is inserted vaginally. It’s not given via IV.

    I agree with you Rachel, it’s pretty disturbing and (I hestitate to add) unbelievable that Cloe’s doc didn’t have any idea that the makers of cytotec will not approve the use of this ulcer medication as a means for induction. There was a nationwide announcement a few years ago to all docs and midwives discouraging its use.

    Cyndi

    http://www.mybirthteam.com

  21. Malia permalink
    October 10, 2007 2:52 pm

    Well then, I’m pretty sure I didn’t get it then. He did “ripen my cervix” in his office the day before but, as I remember it, it was a manual procedure and didn’t include being inserted with any sort of pill. Mostly what I remember is the excruciating pain. I’d never suggest that anyone have that done!

  22. October 10, 2007 3:06 pm

    Malia, would like to hear your story sometime.

    I really want to make it very clear, since Pitocin came up, that I’m not saying, “Boo Cytotec, yay Pitocin” or anything of the sort. I think there are problems with how often other types of inductions are done and the reasons that are given to women for them, aside from the Cytotec issue specifically. I felt like I needed to state that explicitly, because my father-in-law works for the pharmaceutical company that makes Pitocin.

  23. October 10, 2007 3:06 pm

    (And that makes for interesting Thanksgiving conversation)

  24. October 10, 2007 3:20 pm

    Mag, thank you for sharing that. I think it’s an important point, that even going to Special Mom-Friendly Institution doesn’t always guarantee that the practices are what you would want or expect them to be.

    My pleasure, Rachel. I think it’s kind of funny, though… looking back now, I see that it was a Special Mom-Friendly Institution, at least in comparison to other places. But from my point of view as a teenager, I thought it was just shy of absurd.

    “What you want” never seemed to figure into it at all, unless it had to do with a) religious prohibitions or b) what you wanted to drink with your ice chips. From the stories the nurses used to tell about certain doctors, it seems like the big reason for requiring so many drugs and complicated proceedures was so the women were too zonked out to notice what the doctors were doing.

    …Which is not to say they were bad people (they weren’t) or bad doctors (they were well respected and efficient, and didn’t seem to have killed anyone), but that the constraints that they were under (and, admittedly, a certain less-than-caring streak in one of our most efficient doctors) tended to lead them to speed up (leading to mistakes) and use proceedures that they otherwise wouldn’t consider.

    This ranged from inducing immediately upon arrival (“Okay, your appointment was for 4:00. You haven’t eaten anything, have you? Change into this gown, go to the bathroom, and we’ll start the drip.”) to baby football (“Well he didn’t actually drop the kid… it just slipped, and he did the funble fumble fumble thing with it…”) to exessive force in manual assistance (“massaging the uterus” turned into “Oh my god, he just punched that woman in the abdomen!”). And, yes, to having the process being almost entirely nurse and volunteer run, up to the minute the kid crowns… at which point the doctor (who had generally just arrived at the hospital, by virtue of having to serve multiple sites at once) would sprint into the room, catch the baby, possibly cut the cord, and sprint back out, possibly without talking to the woman.

    … and this place still sounds better than most of the stories that I’ve heard. *sighs*

  25. October 10, 2007 3:26 pm

    Malia, one more thing. The current laws governing such things mean that you have an absolute right to review a copy of your medical record, if you want to find out for certain.

  26. Donna Locke permalink
    October 10, 2007 11:41 pm

    In my observation and experience, I concluded that labor induction, drugs, and C-sections are mostly for the doctors’ convenience.

    Things can go wrong. Very wrong. Even with the injections. One of my relatives has a permanent spinal injury because of such an injection. Moms, be careful what you agree to. The baby should come at its and the mother’s body’s signals if at all possible.

  27. October 11, 2007 12:04 am

    Balance is the key…

    Use intervention to help …not hinder

    There are pros and cons to all methods.

    We need to remember (and remind) the power of common sense.

  28. Hildy permalink
    October 22, 2007 3:32 am

    I’m not defending the use of off-label misoprostol for IoL, but there are multiple issues at play here. Ina May Gaskin seems to be attacking the use of all induction agents. The WSMV piece is specifically about misoprostol. Marsden Wagner specifically attacks misoprostol’s off-label use, but does not mention whether the complication rates are similar for misoprostol as for prostaglandin analogues specifically marketed for induction. I do not have that data readily at hand, and I don’t know if it’s available.

    I know of several hospitals which use misoprostol over say dinoprost purely on a cost basis. I don’t have the outcomes data.

  29. October 22, 2007 7:51 am

    Hildy, my understanding is that both Gaskin and Wagner believe induction is done too often when not medically necessary.

  30. November 21, 2007 4:49 am

    Dear Rachael,
    Found your website whilst trying to find info. I am from Australia( it is a little amateur, my website that is and was driven by the need for more woman centred care options here). We currently have some cases of misoprostol use for IOL that have gone thru the judical system and the first has settled for the plaintiff, reasoning absence of informed consent, babies all affected. I am hunting info, have the Marsden Wagner piece, in your dialogue did you get links and info from other sources?
    Appreciate it if you do know and can contact me
    Regards
    Janie

  31. November 21, 2007 3:24 pm

    Janie, send me an email through the Contact form and let me know what you’re looking for – I might be able to help.

  32. Malia S permalink
    March 5, 2008 2:18 am

    Thank you for working to educate women. I was lead to this site by Ina May Gaskin’ book title “Orgasmic Birth”. The action of the title is probably one of the best methods of induction possible.. and she can do it alone or with her partner.

    Simple true story: water broke, leak only, excellent OBGYN said as long as I came in daily to be checked for infection he would allow me to wait up to 10 days. Getting nervous, I went into the shower, enjoyed the power of the water to induce orgasm, which immediately started gentle waves of contractions which soon increased and I had a wonderful totally natural delivery in the hospital. The doctor arrived late never expecting a first baby to be delivered so quickly.. Child birth is wonderful and I definitely believe it is “85%” or more mental conditioning. If the mother is frightened = trouble. If she believes it will be wonderful the pain will be short and clearly worth it. Thank YOU

  33. August 10, 2008 7:46 pm

    sxiaj

  34. November 26, 2008 4:01 pm

    bevf

  35. May 26, 2010 5:27 am

    Thanks for this post. I got cytotec for a missed miscarriage, and was not told that it was off-label. I was told by the midwife that it would help my m/c happen “naturally” and that I shouldn’t make plans for dinner. My husband ended up calling 911 after I lost consciousness from the pain and contractions. My cervix never opened, I got an infection, and had to have an emergency D&E. I’m so scared of this drug and of induction in general, and all that led me to homebirth.

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